Marin Pregnancy Clinic is a nonprofit community clinic in Novato, Calif., with the mission of providing medical care, counseling, and practical solutions to women facing unexpected pregnancies. It is dedicated to reaching women, men, and families in the community through education and support, while providing care for their unborn children. From a modest start in 1987, the clinic now provides pregnancy options counseling, pregnancy tests, sonograms, lab work, and prenatal care up until seven months of gestation. In 2008, it obtained status as a presumptive Medi-Cal provider making them eligible for reimbursement of costs for qualified patients. This year, Marin Pregnancy Clinic faced two major conflicts with other community organizations. The following is the story of how they overcame defeat and discrimination.
“You don’t qualify. . .”
Within the last few years, changes in the structure of Medi-Cal at the State and County levels have impacted Marin Pregnancy Clinic’s ability to reach women in need. The County of Marin hired a new company to provide managed care, Partnership Health Plan (PHP). Under the program, new enrollees in Medi-Cal usually have their care managed through PHP, which provides a directory of “approved” providers for their members to choose from in obtaining care. Participation in this directory is an essential aspect of reaching new clients as it is the main way for patients to find out about their care options.
When the approved provider directory was first published, Marin Pregnancy Clinic was not included. Planned Parenthood was listed, but not the clinic that would provide alternatives to abortion. Marin Pregnancy Clinic’s Director, Robin Strom, realized that not being on the list would mean new clients would generally not even know the clinic existed. She started making calls to ask about the process of becoming an approved provider through PHP. She was told that Marin Pregnancy Clinic would not qualify because it does not provide prenatal care through all nine months of pregnancy and does not provide birth and delivery care. Mrs. Strom explained that Marin Pregnancy Clinic has a very effective referral system in place for patients past seven months. Explanations notwithstanding, staff at PHP refused to consider Marin Pregnancy Clinic as a potential PHP provider.
Ms. Strom realized that PHP’s explanation for excluding Marin Pregnancy Clinic based on a lack of “full-term care” failed to ring true since Planned Parenthood (which does not generally provide these services) was an approved provider.
Faced with this unequal treatment, and stonewalled for answers, Mrs. Strom refused to give up. For approximately a year she explored ways to join the PHP network—always receiving the same unsatisfactory answers. “I knew I couldn’t give up,” Mrs. Strom explains. “We had come so far to achieve presumptive status with Medi-Cal, we couldn’t back away when we were right.”
Unsure what her next step should be, Mrs. Strom shared her concerns with Anne O’Connor, General Counsel of the National Institute of Family and Life Advocates (NIFLA). As a former LLDF board member, who has worked with Life Legal Defense Foundation on California matters in the past, Anne referred the question to LLDF. Working together, Mrs. Strom and LLDF lawyers drafted a letter to PHP setting out the problem, and asking for clarification of PHP policies.
The week after sending the letter, Mrs. Strom received a call from Mary Kerlin, the Director of Provider Relations at PHP expressing a complete change of tune. Ms. Kerlin assured Mrs. Strom that there would be no problem with contracting with Marin Pregnancy Clinic, and that once the contract was finalized, they would have full participation in PHP directories and programs.
After submitting all the required paperwork, Marin Pregnancy Clinic received its approved provider agreement on July 18, 2013, and is now a fully contracted PHP provider. Ecstatic with these results, Mrs. Strom gives the glory to God: “It is great having God on our side. Our ‘mantra’ has been—we wait and we wait and we wait on Him. Now what He will do remains to be shown.”
But that was not the only challenge Marin Pregnancy Clinic was to face this year.
“Don’t ‘dump’ patients. . .”
In Marin County, the largest health care provider for Medi-Cal patients is Marin Community Clinic (MCC). As in most managed health care systems, a patient has a primary care provider and then receives specialty care as approved by the primary care physician. MCC provides primary care as well as prenatal care.
Staff at MCC have complained from time to time about patients who receive their primary care from MCC going to Marin Pregnancy Clinic for prenatal care. (As a limited services pregnancy center, Marin Pregnancy Clinic does not provide primary health care. However, it is a presumptive Medi-Cal provider, and provides specialty care related to pregnancy.) Patients faced with pressure from MCC sometimes stopped coming to Marin Pregnancy Clinic for prenatal care. But the hostility from MCC reached a new height this spring and ultimately landed a patient in the emergency room.
On May 17, 2013, an expectant mother and patient at Marin Pregnancy Clinic called for advice because she was suffering from flu-like symptoms. Her symptoms were such that the staff encouraged her to get an appointment with her primary care provider. Since MCC was listed on the patient’s Medi-Cal card as her primary care provider, she contacted MCC to set up an appointment. Staff at MCC responded that if she were not coming to MCC for her prenatal care, she would not receive an appointment for any other type of care. MCC’s nurse stated that it was unfair for Marin Pregnancy Clinic to “dump” patients on MCC, and utterly refused to listen to the patient’s perspective. Unable to see her primary care physician, the patient ended up in the emergency room. She describes her experience:
“I had to go to Novato Community Hospital Emergency Room . . . where I was diagnosed with bronchitis, a bladder infection, and severe dehydration. . . . I was very frustrated that I couldn’t be seen at MCC and I felt too sick and too weak to defend myself. . . .”
Subsequently, a nurse in MCC’s maternity department called Marin Pregnancy Clinic on a diatribe about “dumping patients” on MCC. She spoke with Marin Pregnancy Clinic’s Director of Operations, Alison Oblites, and angrily expressed that she felt it was inappropriate for one of Marin Pregnancy Clinic’s patients to call MCC regarding anything. She refused to consider MCC’s duty to treat patients for whom it is the contracted primary care provider. As Mrs. Oblites explains, “She made it clear to me that Marin Pregnancy Clinic’s patients would be turned away every time, unless they transferred their care to Marin Community Clinic.” Mrs. Oblites was stunned by the position MCC was espousing, as well as by the unprofessional, vehement tone of the confrontation. Following this experience, Mrs. Strom felt that enough was enough. It was time to hold MCC accountable for its duty to its patients and its position as the largest primary care provider in the County. She asked Life Legal Defense Foundation to work with her in drafting an appropriate letter that would both complain about the offending conduct and demand that MCC accept and abide by its duty.
In researching the rules and policies that apply to a primary care provider in Marin County, LLDF attorneys found that—not surprisingly— MCC’s actions were exactly opposite of what they should have been. LLDF Staff Counsel comments, “Not only was MCC’s conduct unbecoming to a clinic providing care to low-income patients, it was also a failure to follow the policies applicable to a primary care provider.” Under the applicable polices, pregnancy testing, counseling and prenatal care is entirely within the control of the patient, and a primary care provider cannot insist that a patient go through their organization for such care. As if that were not enough, landing a patient in the emergency room for basic care is exactly what managed health care is intended to avoid. The letter asked that MCC take steps to properly train staff regarding patient choice so that such an incident would not occur again. “Our goal was to facilitate communication between Marin Pregnancy Clinic communicate and MCC, so that the appropriate policies would be followed going forward,” says Ms. Millard.
Less than a week later, Mrs. Strom received a call from MCC’s CEO, Dr. Tavaszi, with her apologies and assurance that the incident would not be repeated. She expressed her desire that the two clinics work together in serving the community, and asked that Mrs. Strom speak with the MCC clinic manager to find common ground going forward. Of course, Mrs. Strom was glad to agree—she had been trying for years to open a dialog with clinic management.
“The recent experiences of Marin Pregnancy Clinic go to show what can be accomplished by working together,” comments Dana Cody, President of LLDF. “We commend Marin Pregnancy Clinic, and especially their director, Robin Strom, for being willing to fight for what is right in both of these situations. LLDF is proud to be able to fulfill our mission by assisting Marin Pregnancy Clinic to more effectively defend life every day!”